Common use of Chiropractic Services Clause in Contracts

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomymicro phlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. rhinoplasty.‌‌‌ This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons reason unrelated to care for gender dysphoria and medically necessary Medically Necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, calluses is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. . Coverage of diabetes services requires medical diagnosis of diabetes from a licensed practitioner/provider. Equipment, appliances, prescription drug. Medications, insulin or supplies must have FDA approval and are the medically accepted standards for diabetes treatment, supplies, and education. Coverage for Diabetes Education must be: • medically necessary, or • due to a significant change in condition or symptoms, or • when re-education is prescribed by a practitioner/provider, or • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed health care professional with recent education in diabetes management or • Related to medical nutrition therapy Diabetes supplies and services: • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • · Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomymicro phlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Coverage of diabetes services requires medical diagnosis of diabetes from a licensed practitioner/provider. Equipment, appliances, prescription drug medication, insulin or supplies must have FDA approval and are the medically accepted standards for diabetes treatment, supplies, and education. Coverage for Diabetes Education must be: • Medically necessary • Due to a significant change in condition or symptoms • When re-education is prescribed by a practitioner/provider • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed health care professional with recent education in diabetes management • Related to medical nutrition therapy Diabetes supplies and services • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. rhinoplasty.‌‌‌ This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Aids‌‌‌‌‌ Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. rhinoplasty.‌‌‌‌ This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Aids‌‌‌‌ Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomymicro phlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Coverage of diabetes services requires medical diagnosis of diabetes from a licensed practitioner/provider. Equipment, appliances, prescription drug medication, insulin or supplies must have FDA approval and are the medically accepted standards for diabetes treatment, supplies, and education. Coverage for Diabetes Education must be: • Medically necessary • Due to a significant change in condition or symptoms • When re-education is prescribed by a practitioner/provider • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management • Related to medical nutrition therapy Diabetes supplies and services • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances ed with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomymicro phlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. rhinoplasty.‌‌‌‌ This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Aids‌‌‌‌ Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. rhinoplasty.‌‌‌‌‌ This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Aids‌‌‌‌ Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomymicro phlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Coverage of diabetes services requires medical diagnosis of diabetes from a licensed practitioner/provider. Equipment, appliances, prescription drug medication, insulin or supplies must have FDA approval and are the medically accepted standards for diabetes treatment, supplies, and education. Coverage for Diabetes Education must be • Medically necessary • Due to a significant change in condition or symptoms • When re-education is prescribed by a practitioner/provider • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management • Related to medical nutrition therapy Diabetes supplies and services • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Surgery‌‌‌‌ Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons reason unrelated to care for gender dysphoria and medically necessary Medically Necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, calluses is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. . Coverage of diabetes services requires medical diagnosis of diabetes from a licensed practitioner/provider. Equipment, appliances, prescription drug. Medications, insulin or supplies must have FDA approval and are the medically accepted standards for diabetes treatment, supplies, and education.‌ Coverage for Diabetes Education must be: • medically necessary, or • due to a significant change in condition or symptoms, or • when re-education is prescribed by a practitioner/provider, or • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management or • Related to medical nutrition therapy Diabetes supplies and services: • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Replacement‌‌‌‌ Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Coverage of diabetes services requires medical diagnosis of diabetes from a licensed practitioner/provider. Equipment, appliances, prescription drug medication, insulin or supplies must have FDA approval and are the medically accepted standards for diabetes treatment, supplies, and education. Coverage for Diabetes Education must be: • Medically necessary • Due to a significant change in condition or symptoms • When re-education is prescribed by a practitioner/provider • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management • Related to medical nutrition therapy Diabetes supplies and services • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances ed with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Surgery‌‌‌‌ Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons reason unrelated to care for gender dysphoria and medically necessary Medically Necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, calluses is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Coverage of diabetes services requires medical diagnosis of diabetes from a licensed practitioner/provider. Equipment, appliances, prescription drug. Medications, insulin or supplies must have FDA approval and are the medically accepted standards for diabetes treatment, supplies, and education.‌ Coverage for Diabetes Education must be: • medically necessary, or • due to a significant change in condition or symptoms, or • when re-education is prescribed by a practitioner/provider, or • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management or • Related to medical nutrition therapy Diabetes supplies and services: • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Replacement‌‌‌‌ Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons unrelated to care for gender dysphoria and medically necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic Cosmetics results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.

Chiropractic Services. Except as specified under Complementary Therapies in the Benefits Section. • Biofeedback – Except as specified under Complementary Therapies in the Benefits Section. Cosmetic Surgery Surgery‌‌‌‌ Cosmetic Surgery is not Covered. Examples of Cosmetic Surgery that are not Covered include breast augmentation, dermabrasion, dermaplaning, excision of acne scarring, acne surgery (including cryotherapy), asymptomatic keloid/scar revision, microphlebectomymicro phlebectomy, sclerotherapy (except for truncal veins), and nasal rhinoplasty. This plan does not cover cosmetic surgery, services, or procedures to change family characteristics or conditions caused by aging. This plan excludes coverage for cosmetic surgery or services for psychiatric or psychological reasons reason unrelated to care for gender dysphoria and medically necessary Medically Necessary gender confirmation care. This plan does not cover services related to or required as a result of a cosmetic service, procedure, surgery or subsequent procedures to correct unsatisfactory Cosmetic results attained during an initial surgery. Circumcisions, performed other than for newborns, are not Covered unless Medically Necessary. Reconstructive Surgery following a mastectomy is not considered Cosmetic Surgery and will be covered. Refer to the Benefits Section. Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications Cosmetic treatment, devices, Orthotics and Prescription Drugs/Medications are not Covered. Costs for Extended Warranties and Premiums for Other Insurance Coverage Costs for extended warranties and premiums for other insurance coverage are not Covered. Dental Services Dental care and dental X-rays are not Covered, except as provided in the Benefits Section. Dental implants are not Covered. Malocclusion treatment, if part of routine dental care and orthodontics, is not Covered. Orthodontic appliances and orthodontic treatment (braces), crowns, bridges and dentures used for the treatment of Temporo/Craniomandibular Joint disorders are not Covered, unless the disorder is trauma related. Diabetes Services Routine foot care, such as treatment of flat feet or other structural misalignments of the feet, removal of corns, and calluses, calluses is not Covered, unless Medically Necessary due to diabetes or other significant peripheral neuropathies. Coverage of diabetes services requires medical diagnosis of diabetes from a licensed practitioner/provider. Equipment, appliances, prescription drug. Medications, insulin or supplies must have FDA approval and are the medically accepted standards for diabetes treatment, supplies, and education.‌ Coverage for Diabetes Education must be: • medically necessary, or • due to a significant change in condition or symptoms, or • when re-education is prescribed by a practitioner/provider, or • Telephonic visits with a certified diabetes educator (CDE) that are part of our in-network practitioners/providers who are registered, certified or licensed healthcare professional with recent education in diabetes management or • Related to medical nutrition therapy Diabetes supplies and services: • Must use approved brands • Must be purchased at in-network pharmacy, preferred vendor or preferred durable medical equipment (DME) supplier • Insulin pumps are covered only when medically necessary and when prescribed by an in- network endocrinologist • Podiatric appliances for prevention of feet complications associated with diabetes must be medically necessary • Must use preferred prescriptive diabetic oral agents, insulin, blood glucose monitors/meters, test strips for blood glucose monitors, and lancets and lancet devices according to the Formulary Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids Durable Medical Equipment Upgraded or deluxe Durable Medical Equipment is not Covered. Convenience items are not Covered. These include, but are not limited to, an appliance, device, object or service that is for comfort and ease and is not primarily medical in nature, such as, shower or tub stools/chairs, seats, bath grab bars, shower heads, hot tubs/Jacuzzis, vaporizers, accessories such as baskets, trays, seat or shades for wheelchairs, walkers and strollers, clothing, pillows, fans, humidifiers, and special beds and chairs (excluding those Covered under Durable Medical Equipment Benefits). Duplicate Durable Medical Equipment items (i.e., for home and office) are not Covered. Repair and Replacement Replacement‌‌‌‌ Repair or replacement of Durable Medical Equipment, Orthotic Appliances and Prosthetic Devices due to loss, neglect, misuse, abuse, to improve appearance or convenience is not Covered. Repair and replacement of items under the manufacturer or supplier’s warranty are not Covered. Additional wheelchairs are not Covered, if the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair.